key: cord-0816421-iy4vnj9e authors: Joarder, T.; Bin Khaled, M. N.; Zaman, S. title: Health systems trust in the time of Covid-19 pandemic in Bangladesh: A qualitative exploration date: 2020-08-06 journal: nan DOI: 10.1101/2020.08.05.20157768 sha: b052582a0880e22e28392b229f0337d512f20d16 doc_id: 816421 cord_uid: iy4vnj9e Background: Lack of trust hinders care seeking, and limits community support for contact tracing, care seeking, information and communication uptake, multisectoral or multi-stakeholder engagement, and community participation. We aimed at exploring how trust might be breached and what implications this may have in COVID-19 pandemic response by the Bangladesh health systems. Methods: We conducted this qualitative research during the pandemic, through seven online focus group discussions, with purposively selected mixed-gender groups of clinicians and non-clinicians (n=50). Data were analyzed through conventional content analysis method. Results: The common thread throughout the findings was the pervasive mistrust of the people in Bangladeshi health systems in its management of COVID-19 pandemic. In addition to the existing health systems weaknesses, few others became evident throughout the progression of the pandemic, namely, the lack of coordination challenges during the preparatory phase as well as the advanced stages of the pandemic. This; compounded by the health systems and political leadership failures, lead to opportunistic corruption and lack of regulations; leading to low quality, discriminatory, or no service at all. These have trust implications, manifested in health seeking from unqualified providers, non-adherence to health advice, tension between the service seekers and providers, disapproval of the governance mechanism, misuse of already scarce resources, disinterest in community participation, and eventually loss of life and economy. Conclusions: Health sector stewards should learn the lessons from other countries, ensure multisectoral engagement involving the community and political forces, and empower the public health experts to organize and consolidate a concerted health systems effort in gaining trust in the short run, and building a resilient and responsive health system in the long. In general understanding, 'trust' means, if trustors turn to trustees, the trustee would not exploit the trustor, rather, protect the vulnerable trustor from which s/he turned to the trustee [1] [2] [3] [4] . For example, the Covid-19 pandemic has made people vulnerable to the disease, social relations, livelihood, etc. So, the health systems authority is expected to protect the people, and should not exploit them in the face of their vulnerability. Different levels of trust have been theorized depending on whether trust is in a person, a system or institution 2 . Sripad et al. (2018) described 'trust' in terms of interpersonal and impersonal trust in the context of maternity care in Kenya, where they defined the former as the trust between service provider and service seeker; and the latter as that in a social system, such as the health systems 5 . In this article, by 'trust' we refer to the impersonal trust, i.e., the trust of the people in the Bangladeshi health system during the Covid-19 pandemic. Health systems are comprised of persons, institutions or activities whose primary intention is to improve people's health 6 . Ministry of Health and Family Welfare (MoHFW) is responsible for policy, planning, and overall governance of the health sector through different directorate generals, which are responsible for policy implementation. Pandemic response is guided by Infectious Diseases (Prevention, Control and Elimination) Act 2018, which places Directorate General of Health Services (DGHS) as the central coordinating and responsible body for Covid-19 response. Under this; Institution of Epidemiology, Disease Control, and Research (IEDCR) is the main scientific body to provide technical guidance and support for screening at point of entry, quarantine, contact tracing, testing (initially, then later contracted out to other government and a few private laboratories), forecasting, surveillance, and outbreak response 7 . In the urban areas, however, Ministry of Local Government, Rural Development and Cooperatives is responsible for primary level healthcare, while secondary and tertiary care is bestowed upon an unregulated (or poorly regulated) private sector 8, 9 . As of 7 July 2020, 168,645 cases (#17 in the world) have been identified with a death toll of 215 10 , 3rd highest new cases (3027) per day, and one of the lowest rate of tests per million (5, 321) in the world and the second lowest among its South Asian neighbors (only above Afghanistan) 11 . Major events related to Covid-19 pandemic and its response in Bangladesh have been shown in Figure 1 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint Trust is important in health systems as it fosters cooperation among diverse stakeholders and contributes to health production 2 , which are imperative in responding to a pandemic in the short term and building a resilient health system in the longer term. It plays a critical role in garnering social order among the population 2,12 and feeding back into the improvement of the governance as a whole 13, 14 . It improves communication flows which are essential for risk communication to the people in a pandemic 15, 16 , and information flows which are essential for technical and managerial decision-making by experts and managers 2, 17 . Sharing information by cases and contacts (as part of contact tracing activities) is a cornerstone in pandemic response, which depends on public's trust on the health systems and the state at large 2, 15, 17 . Lack of trust may invoke widespread stigma regarding infectious diseases, which severely obstructs case detection, isolation, quarantine, and case management activities 18, 19 . People's trust in health systems improves access, utilization, adherence, and continuity of care, leading to improved health and satisfaction 12, 17, 19 . Not only among the general people, but also among the service providers, trust is important, as it improves motivation and service provision; and lack of it can escalate to strike, e.g., against the lack of personal protective equipment (PPE) and medical equipment 20 Finally, Covid-19 response requires adaptive leadership, i.e., making bold decisions and passing newer regulations with the emergence of newer evidences, which is impossible without trust between decisionmakers and the range of stakeholders and the people 21 . However, while these examples suggest that trust is important in Covid-19 response and developing a resilient health system in the long run, understanding on trust in health systems context is ambiguous. There is only one systematic review on trust measures, and their content areas 12 , and a few other articles on trust and healthcare 2, 3, 5, 22 . Most of the studies, however small in number, are from Western countries 14 . Role of trust in pandemic preparedness and response is rare globally 17 , and absent in Bangladesh. Therefore, this study aims at exploring how trust might have been breached and what implications this may have in regard to the Covid-19 pandemic response by the Bangladesh health systems. This was an exploratory qualitative research, conducted during the lockdown situation of Covid-19 pandemic in Bangladesh, through online focus group discussions (FGDs), to obtain a deeper understanding of the construct of trust in the health systems context of Bangladesh. This research was sponsored by United Nations Youth and Students Association of Bangladesh (UNYSAB), which organized a webinar on 19 May 2020, amid the lockdown situation (officially termed as 'General Holidays') in Bangladesh, on 'Trust in the Health System in COVID-19 Pandemic and Beyond.' Moderated by the first author, the discussants included a public health expert from the not-for-profit private sector (Head of the communicable disease program of a leading non-governmental organization of Bangladesh), a public health expert from the public sector (an Assistant Director of a government health agency of Bangladesh), a health economist (an Associate Professor at a leading Bangladeshi public university), and a female . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint entrepreneur. During the webinar, the moderator and the first author described the basic tenets of trust 12 and asked the discussants about the role of trust in Covid-19 pandemic response, how trust may be breached, how breach of trust may impact the health systems, and what may be done to improve the trust in building a resilient health systems. This webinar helped in gaining a practical overview of the trust situation in Covid-19 crisis response by the Bangladeshi health systems. During the webinar a Google Forms link was circulated by the organizers to collect the name and contact information (name, email, phone number, Skype ID, educational background, and occupation) of interested FGD respondents. We conducted seven FGDs through 15 to 17 June 2020, with the respondents who showed interest in the Google Forms circulated during the webinar. Each FGD, held and recorded through the video conferencing software Google Meet, consisted of 6-10 respondents, selected through purposive sampling method, from the Google Forms list. Each FGD was done with one of the following groups of mixed-gender respondents, categorized into two broad categories: 1) Clinicians: graduate students (all with medicine or dentistry as their undergraduate background) of public health of a private university, renowned public health experts (all with a medicine background), practicing clinicians (with either medicine or dentistry background); and 2) Nonclinicians: undergraduate students of different departments (management, marketing, botany, business, and pharmacy) of a public university, undergraduate students of public health of a public university, undergraduate students of food and nutrition department of a public university, service holders of different professions (executives, trainers, managers, and coordinators of public and private organizations). The FGDs were moderated by the first author, who is a health policy and systems researcher with experience and expertise in qualitative research methods. The second author, trained in economics and experienced in qualitative research, assisted in note taking. The open ended FGD guide addressed three main questions: 1) How trust might have been breached during the Covid-19 pandemic, 2) What are the implications of breach of the trust, and 3) How trust may be restored and improved for a resilient health system. Each FGD, lasting from 60 to 105 minutes, was conducted in Bengali, the native language of the respondents and the researchers. The FGDs were immediately transcribed by the members of UNYSAB, the sponsor of this research. For analysis, we adopted conventional content analysis method 23 which is appropriate in scarcity of existing literature on a phenomenon, as this method avoids using preconceived themes. We developed the inductive categories through the following steps: familiarizing with the data by listening to the records and reading the transcript, developing coding schema in MS Excel based on the three questions mentioned above, noting the first impressions followed by labelling the text segments by newly emerging codes, merging the similar-meaning codes together, then sorting the codes into larger categories based on how different codes are related or linked. Then we applied the concept mapping technique to organize these categories into a hierarchical structure ( Figure 2 ). In order to increase validity, the first and second author independently coded the dataset, and the third author was involved where a third opinion was needed to reach a consensus. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint A total of 50 respondents participated in 7 FGDs ( Table 1) . Age of the respondents ranged from 19 years to 75 years, 28 were males and 22 females. 4 of the FGDs were held with respondents with non-clinical background (n=28) and 3 were with clinicians (n=22). Almost half of the respondents had training in public health. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. Health system of Bangladesh has already been suffering from shortage of budget, lack of quality of services, and a highly centralized secondary or tertiary care. According to the respondents, Covid-19 just exposed the situation: "The lack of trust in health systems predates the Covid-19 situation, and for a right reason. The pandemic simply exposed the fact that the emperor actually has no clothes." (FGD-6, renowned public health experts, clinical background) Pre-existing inadequacies are compounded by the mistakes of the health system actors in the preparatory phase. Respondents observed several mismatches between what have been said and done. The health sector reportedly failed to place right persons in the right position in pandemic response, as expressed by a professor of public health: "An epidemic is a public health emergency; it is neither clinical nor an administrative issue. So, we must see this problem through the public health lens. We [epidemiologists] already know what to do to control an epidemic. … We the public health professionals should be given flexibility that we are free to do whatever is needed for the country, not something that just pleases the political leadership." (FGD-6, renowned public health experts, clinical background) Their lack of preparation is also evident from imposing home quarantine at the beginning of the pandemic, instead of an institutional one, while knowing that, intimate Bangladeshi culture is clearly not conducive to home quarantine. Insufficient testing, delay in giving test results, high cost of diagnosis and treatment in private sector, insufficient equipment in the health centers, etc. also indicate a lack of farsightedness among the health system actors: "We are not getting the test results in time. My friend's father got test report after 10 days, when he was already dead." (FGD-3, undergraduate students of public health of a public university, non-clinical background) . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint Respondents alto think that, not ensuring subsistence allowance for the poor before imposing a lockdown (official term was 'general holiday'), not allowing people to take preparation as they did not mention how long the lockdown might continue, and increasing the duration week by week were signs of unreadiness, leading to ineffective lockdown. The health system actors wasted critical time before allowing private centers, although only a few in number, to provide Covid-19 care; conducting tests from only one government facility during the initial days of the pandemic, and not using alternative testing facilities like all the private and non-governmental organizations' (NGOs') reverse-transcriptase polymerase chain reaction (RT-PCR) and rapid testing facilities. A student of public health said: "Government is allowing, although lately, private diagnostic centers to perform Covid-19 test. But there are many other RT-PCR machines which are not yet being utilized." (FGD-2, graduate students of public health of a private university, clinical background) Lack of coordination among different government departments, between government and other sectors, and with different business agencies regarding whether or when those businesses will open, created a massive confusion. One such incoordination allegedly led to massive spread of the disease among the low-income garment employees: "BGMEA [national trade organization of garment manufacturers] ordered garment workers to return to Dhaka to save their job. After they returned by thousands, braving the coronavirus infection, BGMEA declared that the factories will not open. They (BGMEA) never consulted public health experts or health department. On the other hand, the police announced that they will not allow anyone to enter Dhaka. The innocent workers were caught between a rock and a hard place, just because of the incoordination of different departments." (FGD-2, graduate students of public health of a private university, clinical background) Lack of coordination was also observed in imposing lockdown in periphery areas of the country without arranging the transport of the patients to the centrally located health facilities, declaring several hospitals as dedicated Covid-19 hospitals while these were not prepared, asking private hospital to provide care while testing was not allowed for them to verify if they are admitting Covid-19 positive patients with general patients, suddenly opening markets before Eid vacation while health experts at the government committees were calling this an unscientific decision, etc. A respondent said: " The health systems made several good decisions, but those also faced criticisms for poor management. For example, point of entry screening was weak from the beginning, government officers were seen putting on personal protective equipment (PPE) meant for the doctors and posing on television, etc. Not receiving the PPEs in is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. ." (FGD-3, undergraduate students of public health of a public university, non-clinical background) Apart from the health systems actors, the political leadership of the country are believed to downplay the risk and added fuel to the fire by irresponsible remarks. A popular perception is that the government procrastinated in ramping up the Covid-19 response in the early days of the pandemic with an intention to make some political programs hassle-free. There is an impression that the government put political agenda above health agenda, which allegedly became evident by the incident of disapproving an antibody-based testing kit developed by a local NGO, due to the alleged political affiliation of the leader of that NGO with the opposition party. A doctor said: "We are saying antibody testing is essential, they [the government] are saying no. Are they doing it politically! (FGD-7, practicing clinicians, clinical background) It is also believed that the private testing facilities and hospitals that are getting approval lately have political blessings. A student of public health said: "There is a rumor that government is allowing diagnostic centers those are politically close to them. For example, Popular Diagnostic Center [a private diagnostic company, rumored to have ties with an opposition political party] is denied to conduct tests due to political reasons. This is not the time for politicization." (FGD-2, graduate students of public health of a private university, clinical background) Other criticisms against the political response include positioning the rhetoric of livelihood against life under the pressure of business leaders, giving false hope repeatedly while knowing that they were not prepared, and defending themselves against their failures without confessing their mistakes or apologizing, etc. A respondent said: "If a leader confesses his mistakes, I may be angry at first, but my trust will return, because, he is telling the truth, at least." (FGD-5, service holders of different professions, non-clinical background) Incidents of several corruptions made to the media, many of which are perceived to be linked with politics. For example, many PPEs were found to be counterfeit yet got approved by the health department, several decisions to protect the interest of the businessmen were seen as an offshoot of political consociation, etc. Lack of regulation was another complaint, examples of which include: high price of essentials due to panic buying, mushrooming of unauthorized and even fake testing centers, uncontrolled advertisement and selling of putative Covid-19 medicine (e.g., is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint hydroxychloroquine, ivermectin, remdesivir, etc.), and lack of action against the false Covid-19-negative certifications: "Today I saw in the news that, someone who had been found corona negative here, was found positive after landing in Japan. So, when things like these happen, it calls upon our trust. These instances may even adversely affect our foreign relations." (FGD-5, service holders of different professions, nonclinical background) Trust has been breached by low quality services due to scarcity of essential facilities like intensive care unit (ICU) beds, equipment like ventilators, oxygen supplies, etc. These are supplemented by the information that private hospitals are denying to admit patients without Covid-19-negative certificate; obtaining which takes long time due to lack of adequate testing facilities, eventually deteriorating the condition of the patients. Those with respiratory symptoms suffered the most, leaving several patients dead in the process of back and forth between multiple hospitals. These allegations were compounded by the rumors of private hospitals keeping patients admitted for more money even after getting cured, charging astronomical amount of money for scarce services like ICU or oxygen, taking patients hostage for money, etc.: "My relative was kept in a private hospital for extra three days after she was found covid negative. She was even given oxygen. When asked why, they said it is for extra safety of the patient." (FGD-3, undergraduate students of public health of a public university, non-clinical background) Discriminatory care was the worst allegations against the health system. There are circulating stories of high profile people booking the whole hospital for their family members, leaving country of some business tycoons by air ambulances or chartered flights, and the alleged reservation of a public hospital only for the so called 'veryimportant-persons', known popularly as VIPs: "We are seeing that wealthy and political people of the ruling party are getting one type of treatment, while general people are getting something different. Some managed to go out of the country by chartered flight, some ministers booked ICUs even before requiring one. Hearing such news, as a middle-or lower-middle-class member of the society, I can't help losing trust in the health system. All facilities are there to protect the upper layer of the society." (FGD-4, undergraduate students of food and nutrition department of a public university, non-clinical background) Taking service by government health sector high officials not from public sector hospitals but from a well-known military hospital instigated much mistrust among the people, as expressed by a physician: "When the top government health officials take treatment from the Combined Military Hospital, how can others keep trust on the government health system? What can be more painful than this?" (FGD-7, practicing clinicians, clinical background) As a result of longstanding pre-existing health systems constraints, people will resort to popular or folk sector, especially with rising popularity of app-or web-based selfmedication options. Seeking treatment from abroad is already a popular tendency, which will increase, leading to further loss of foreign currency: "High income group will go abroad for simple cases, low income group will go to unqualified providers, middle class people like me will have nowhere to . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint go." (FGD-2, graduate students of public health of a private university, clinical background) As a result of lack of proper preparation and coordination, people would refrain from seeking care, i.e., they will not get tested, go to health facilities, maintain quarantine, self-isolate if suspected of or diagnosed with Covid-19, and eventually further spread the disease: "General people like us will develop hesitation in their mind to seek healthcare. They will hesitate to get tested, which is the first step after suspecting Covid-19. They will not know whether they are infected or not and eventually infect their family members." (FGD-1, undergraduate students of different departments of a public university, non-clinical background) Ineffective lockdown and other missteps sparked a negative perception and suspicion among the general people which made them disbelieve even the correct information and government directives. People's disbelieves range from the number of Covid-19 positive cases reported by the government to the information shared on social distancing and other hygiene measures. A respondent said: "When the schools were closed, my mother went to Kutubdia [a distant island, respondent's ancestral home] with my siblings. I heard from her that people of Kutubdia are not even believing that any such disease even exists in reality. They think it's a hoax, or a propaganda being spread by the government for a clandestine purpose. People are not abiding by any health messages delivered by the government. (FGD-5, service holders of different professions, nonclinical background) Loosing trust on the doctors, people may not adhere to the doctor's advice, health messages, and treatments. People consider doctors or service providers as the representative of the health system, although, according to the FGDs with the clinicians, they are none but the victims of the system itself. But people often show aggression against the doctor; even a doctor was recently murdered by a dead patient's aggrieved relative: "A doctor has been beaten to death, but nothing has happened yet. … We the doctors always bear the burden of breach of health systems trust." (FGD-7, practicing clinicians, clinical background) People will lose trust on the overall governance and the political system of the state, as a result, even the positive achievements will be disapproved by the people, demotivating the political leadership: If is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint admitted, such as those who are having mild symptoms. I know people who, despite having mild symptoms, are occupying hospital beds unnecessarily. Why? Because they are afraid that they may not find a hospital bed a few days later if such a need arises. Even some people, who are not sick, have just booked cabins in case they need it sometime in the future. These could be avoided, had we been able to convince people that they will get necessary healthcare in time of emergency." (FGD-6, renowned public health experts, clinical background) Negative perceptions and suspicion towards the system is a perfect recipe for stigma, mental health conditions, lack of community interest and engagement for a collective response. A respondent said: "People feel insecure which may have a negative impact on mental health. People are so insecure that it has made them inhuman too. We heard that a son has left his mother in a jungle when she developed symptoms of Covid-19. We ourselves are experiencing the effects of stigma too, as many physicians are driven out of their homes by their landlords fearing spread of infection to their apartment." (FGD-2, graduate students of public health of a private university, clinical background) Psychological impact of the whole failure would frustrate the people, and young people will leave the country. Both health and economy of the country will fall inside a positive feedback loop. A professor of public health said: "We often say that public health is about saving lives in millions. But a blunder in public health can jeopardize the lives of millions too." (FGD-6, renowned public health experts, clinical background) A summary of the findings and the recommendations are given in Table 2 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . The common theme throughout the qualitative findings was the pervasive mistrust of the people in Bangladeshi health systems in its management of Covid-19 pandemic. This mistrust arguably stemmed from the existing health systems weaknesses, supplemented, throughout the progression of the pandemic, by, the lack of coordination challenges during the preparatory phase as well as the advanced stages of the pandemic. This; compounded by the health systems and political leadership failures, lead to opportunistic corruption and lack of regulations; leading to low quality, discriminatory, or no service at all. These have trust implications, manifested in health seeking from unqualified providers, nonadherence to health advices, tension between the service seekers and providers, disapproval of the governance mechanism, misuse of already scarce resources, disinterest in community participation, and eventually loss of life and economy. Understanding of these findings is important in reorganizing, restructuring, and revamping Bangladesh's response towards Covid-19 pandemic. One of the predictors of mistrust in Covid-19 response was the lack of coordinated actions. Many respondents, especially those with a public health background indicated that, this happened, because appropriate experts were not engaged since the early days of the pandemic. This is supported by the news articles and reports from Bangladesh. Bangladesh detected the first Covid-19 case on 8 March and experienced the first death on 18 March, but it formed the 17-member National Technical Advisory Committee (NTAC) On 19 April 2020. Until then, most of the pandemic control efforts were taken by the administrators, many of whom lacked expertise or experience in health, let alone pandemic management. Even the NTAC was devoid of adequate public health representation; among the 17-member committee, only three had a public health career track, others were high-profile clinicians such as neonatologist, endocrinologist, obstetrician, gastroenterologist, otolaryngologist, internal medicine specialist, anesthesiologist, psychiatrist, and so on 24 . On 21 April, the government made another announcement on assigning 64 top bureaucrats to supervise and coordinate relief distribution activities in 64 districts of Bangladesh 25 . The professionals were ignored once again in technical leadership for pandemic control, both at the central government and the local (i.e., district or sub-district) levels. A policy analysis on the human resources for health in Bangladesh also revealed that the DGHS is principally managed by the clinicians at the expense of public health experts. At the MoHFW level, the top health-bureaucrats are mostly drawn from other ministries, often unrelated to the health sector 26 . Another theme that emerged as the determinant of health system trust was leadership, both in the health system and the political sphere. Ramalingam et al. (2020, p.2) argued, addressing a poorly understood and rapidly evolving disease like Covid-19 demands 'adaptive leadership', which cannot be achieved by "a small number of people behind closed doors." 21 They further added, implementation new policies and changing them as needed require candid and trustful relationships between policymakers and different stakeholders. This, however, is not the usual modus operandi in many countries, and our data indicates, Bangladesh is one of those countries. Participation, transparency, fairness, and trust-building-these 'soft capacities' are now considered as inseparable part of modern health system governance 27 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint Corruption, lack of regulation, rent seeking behavior by the health systems and political actors came out as dominant feature during the pandemic control. Bangladeshi newspapers support this perception of the people, by publishing articles on corruptions by companies or persons with alleged ties with the ruling political party. Such corruptions include, but are not limited to, granting permission for Covid-19 test to lesser known institutions which delivered false reports, approving low quality health products from corrupt companies, etc [28] [29] [30] . A study by Transparency International identifies major health sector irregularities, which include politically influenced recruitment, transfers and promotions of healthcare professionals, irregularities in the procurement of drugs and equipment, unregistered and unqualified doctors operating in private healthcare facilities, and absenteeism 31 . A recent article, drawing examples from the Ebola crisis in Africa, demonstrated, how corruption erodes trust in the health system to the detriment of overall population health 32 . It was evident from the remarks of the respondents that the lack of coordination and leadership in pandemic response led to mistrust and subsequent consequences, such as social stigma, psychological impact, and further spread of the disease. Zaman et al. (2020) in their rapid anthropological study, found that the information provided by the health system carried a varied meaning for the general people, both in urban and rural Bangladesh. The terms widely circulated by the media and the health authorities, such as quarantine, social distancing, lockdown, etc. were seen as foreign, ambiguous, and difficult to fit to the general Bangladeshi people's context. The health messages thus circulated by several government and non-government organizations, largely in an uncoordinated manner, failed to synchronize with people's social and economic reality, level of understanding, and risk perceptions 33 . Apart from noncompliance, different recent studies reported mistrust in the health system leading to widespread social stigma, fear, discrimination, rumor 34 , as well as psychiatric conditions 35 , even suicide 36 . The preexisting health systems issues are widely discussed in many literatures on Bangladeshi health systems, especially in 'Bangladesh Health Sector Profile' by the World Bank; and 'Bangladesh Health System Review' 37 and 'Joint External Evaluation of IHR Core Capacities' by the World Health Organization (WHO) 38 . These well-known health system weaknesses need to be addressed first, in consultation with health policy and systems experts. Next, to improve the coordination and science-based professional response to Covid-19 pandemic, the relevant experts for pandemic management should be immediately engaged and deployed. Such experts may include; but not limited to; public health professionals; including infectious disease epidemiologists, health policy and systems experts, medical anthropologists, health economists, health communication experts; laboratory scientists, including virologists, microbiologists, biochemists, lab technicians; relevant clinicians; including physicians, nurses, paramedics; and not merely administrators or bureaucrats. In the long run, however, a separate public health track in the health sector is indispensable 26 . In order to facilitate an adaptive leadership, health system should ensure transparency in every aspects of its functions. To curb corruption and discrimination, it is important to take punitive actions, dissolve the unholy syndicates, ensure accountability, regulate private sector for cost and quality of services, and make sure no service . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint provider can ever deny giving healthcare to any patient irrespective their social, economic, political, religious, gender, or any other kind of identity. Politicians in power should engage with other social, cultural and religious forces and formally engage with other political parties in facing the Covid-19 crisis, with a view to fostering multisectoral collaboration and community engagement 20, 27, 39 . Finally, we recommend to ensure a free flow of correct information following evidence based, scientifically oriented social and behavior change communication (SBCC) strategies; restrict spreading misinformation; establish an effective communication channel up to the rural level; engage religious, cultural, political, and community based forces in message delivery; and formulate and implement an explicit policy and guideline to promote a culture of respect to counteract social stigma against Covid-19. WHO published the risk communication and community engagement (RCCE) action plan, where they discussed about regular and proactive communication with the public and at-risk populations to reduce stigma and build trust for the people and their families 40 . Information should be clearly and widely circulated for different groups, such as, the villagers, slum-dwellers, township residents, urban middle-class, etc. through contextually appropriate communication channels. Since this study explored only the impersonal trust perception of the people in health system, a separate study my explore interpersonal trust, i.e., the trust between the people and the service providers. Secondly, a study on health systems governance may be conducted to obtain both the perspectives of the government actors as well as that of the other stakeholders outside the government. Patients' perspective of the responsiveness of the service providers, and service providers' perspective on their own safety and experiences of Covid-19 response could be other interesting areas to explore. There are limitations to this study, such as, we could not achieve methodological or source triangulation due to the constraints of the pandemic situation. Secondly, the first author himself was a Covid-19 patient during the whole period of conducting this research. Given the sufferings of the disease and frustration of increasing rate of infection in the country, it is not unlikely to interpret the qualitative findings in a negative light. However, we tried to compensate for this by triangulation through multiple analyses 41 , i.e., by engaging multiple research team members in coding the data and interpreting the findings. Another limitation is that, since we had to conduct the FGDs online, we could not capture the perceptions of those who do not have access to internet, i.e., the less disadvantaged group, who may have less trust in the health systems. Also, we failed to capture the perspectives of the health systems policy or governance actors who are dealing with the Covid-19 pandemic on the ground. Therefore, it is important to keep in mind that this study reflects only the perceptions of a specific section of the society, and may not reflect the actual situation of health system governance in responding to Covid-19 pandemic. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20157768 doi: medRxiv preprint What does it mean to trust a health system? A qualitative study of Canadian health care values Trust and the development of health care as a social institution Trust in health care: theoretical perspectives and research needs Public Trust in Health Information Sharing: A Measure of System Trust Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis Health systems: Improving performance. Geneva: World Health Organization;2000. 7. 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Vector Borne Zoonotic Diseases The emergence of dengue in Bangladesh: epidemiology, challenges and future disease risk Dengue Situation in Bangladesh: An Epidemiological Shift in terms of Morbidity and Mortality Pandemics have been known to the humans since the beginning of the recorded history, and perhaps even predate 42, 43 . Covid-19 may be the first documented coronavirus disease 44 , but may not be the last. Bangladesh experienced several local disease outbreaks over the past several years [45] [46] [47] [48] and a recent dengue epidemic in 2019 49 . However, due to their lower magnitude compared to the Covid-19 pandemic, the need for a comprehensive overhauling of the health systems had not been felt so deeply. Low-and Middle-Income Countries like Bangladesh are particularly vulnerable to pandemics due to their week governance and health systems preparedness 27 . Therefore, a resilient health system is indispensable. The concept of 'resilient health systems' gained traction during the 2014-2015 Ebola epidemic in West Africa. Experts considered resilient health system as the precondition for combating future epidemics effectively. Resilience means the degree of change a health system can endure while maintaining its functionality 17 . A common thread in the resilience literature is the centrality of 'trust' in building resilient health systems 15 . In this article, we explored the pathways of breach of trust in health system during a pandemic situation. We realized many of the mistrusts stemmed from the already fragile and unprepared health system of Bangladesh compounded by lack of coordination and adaptive leadership. Based on our findings we recommend our health systems leaders to introspect and learn from the mistakes, in order to prevent a longer-term loss of life and economic downturn. We also feel that, our health sector stewards should take advantage of the lessons from other countries, ensure multisectoral engagement involving the community and political forces, and empower the public health experts to organize and consolidate a concerted health systems effort in gaining trust in the short run, and building a resilient and responsive health system in the long.